Pasteurella Multocida Pneumonia with Hemoptysis a Case Report

Respiratory Medicine Case Reports 26 (2019) 31–34

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Respiratory Medicine Case Reports

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Case report Pasteurella multocida pneumonia with hemoptysis: A case report T ∗ Yuka Aida, Takumi Kiwamoto , Kazutaka Fujita, Hiroaki Ishikawa, Haruna Kitazawa, Hiroko Watanabe, Nobuyuki Hizawa

Department of Pulmonary Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan

ARTICLE INFO ABSTRACT

Keywords: Pasteurella multocida, which colonizes upper respiratory and digestive tracts, is a leading cause of respiratory Pasteurella multocida diseases in many host species. Here, we describe a case of P. multocida pneumonia with hemoptysis. A 72-year- Pasteurella canis old female diagnosed with bronchiectasis with a 36-year history presented with a worsened infiltrative and Hemoptysis granular shadow in the lower right lobe and lingular segment. Bronchial lavage fluid culturing suggested Pasteurellosis Pasteurella pneumonia. P. multocida was confirmed by 16S rRNA sequencing. The patient was readmitted toour hospital because of hemoptysis, and she was treated successfully with antibiotic therapy. The possibility of P. multocida infection must be considered in patients who own pets.

1. Introduction lingular segment with several episodes of hemosputum. She also received clopidogrel to maintain a stent inserted for cerebral aneurysm. Pasteurella multocida, a small gram-negative coccobacilli belonging She had pet cats and slept with them for almost 30 years. to the Pasteurellae family, colonizes the upper respiratory and digestive Physical examination at admission was unremarkable. Laboratory tracts of several wild and domestic mammals [1,2]. P. multocida is also findings, including white blood cell count and C-reactive protein levels, known to be a zoonotic agent in humans [3]. The commonest human were normal. T-SPOT.TB test for tuberculosis and serum anti- infections caused by Pasteurella are local wound infections resulting Mycobacterium avium complex antibody level was negative. Chest from animal bites and scratches. This infection also has been reported computed tomography (CT) revealed worsened bronchodilation, bron- to cause severe complications, such as septic arthritis, meningitis, chial wall thickness, centrilobular nodules, and air-space consolidation peritonitis, sepsis, abscess, and pneumonia [1–3]. Pasteurellosis is also in the lower right lobe and lingula (Fig. 1A). caused by licks on skin abrasions and due to contact with mucous se- Bronchoscopy was performed to confirm the pathogen identity. A cretions derived from pets. The respiratory tract is the second most large amount of purulent sputum was observed in the lingular seg- common site of P. multocida infection; P. multocida is usually recognized ments (Fig. 2A). Cultures of wash specimens from the right B8a and as a commensal organism in patients with chronic pulmonary disease. lingular segments revealed gram-negative rods (Fig. 2B), which using However, in some cases of pulmonary pasteurellosis, serious respiratory Vitek 2 testing, were identified as P. canis with a 91% identification tract infections can develop and can be fatal [1–4]. Here, we report the probability. In addition, culturing using MacConkey agar was negative case of P. multocida pneumonia in a 72-year-old female with bronch- for bacterial growth; isolated bacteria could not dissolve maltose and iectasis and worsening hemoptysis. mannitol, but could dissolve ornithine. These results were consistent with those obtained for P. canis. Because P. canis quite rarely causes 2. Case report pneumonia, we performed 16S ribosomal RNA (rRNA) sequencing for confirming the diagnosis; the isolates were identified as P. multocida A 72-year-old Japanese female was admitted to Tsukuba University subsp. septica with a 99.9% probability (Fig. 2C). Based on these re- Hospital (Tsukuba, Japan) in September 2015 with aggravation of sults, P. multocida pneumonia was finally diagnosed. While waiting for consolidation in the lingular segment. She had never smoked; however, the rRNA sequencing analysis results, the patient suffered worsened she had a 36-year history of bronchiectasis in the lower right lobe and hemoptysis and was readmitted to our hospital in October (Fig. 1B).

∗ Corresponding author. Department of Pulmonary Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan. E-mail address: [email protected] (T. Kiwamoto). https://doi.org/10.1016/j.rmcr.2018.11.004 Received 9 August 2018; Received in revised form 3 November 2018; Accepted 3 November 2018 2213-0071/ © 2018 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/). Y. Aida et al. Respiratory Medicine Case Reports 26 (2019) 31–34

Fig. 1. CT images indicate bronchodilation, thickness of the bronchial wall, centrilobular granular shadow, and consolidation in the lingular and right S8 segments (A). Both of these lesions became worse when the patient suffered hemoptysis (B) and then improved after antibiotic treatment.

Intravenous ampicillin/sulbactam (9.0 g/day) was administered for However, the identification of clinical Pasteurella isolates by Vitek 2 is one week, followed by oral amoxicillin-clavulanic acid (750 mg/day) controversial. Zangenah et al. reported that Vitek 2 could only for another 30 days. After antibiotic therapy, the lower right lobe and identify 48.5% of Pasteurella isolates correctly and failed to identify P. lingular shadows were extremely improved (Fig. 1C). She was dis- multocida in more than 50% of the cases [10]. Although Vitek 2 is a charged on day 25 without any complications. Before discharge, we rapid and useful diagnosis system, a different confirmation approach instructed her to strictly wash her hands after contact with her cats; is recommended before final diagnosis. P. multocida isolates are we also instructed her to keep the cats away from her bed. We fol- classified into five capsular types and eight lipopolysaccharide (LPS) lowed-up with her two years after her discharge, during which she had types [11,12]. Multiplex PCR for capsular and LPS typing, is a fast, no symptoms of hemosputum related to pasteurellosis. Written in- simple, and cheap method for genotyping [11,12]. Although the formed consent was obtained from the patient for publication of the mechanism by which these type differences affect strain virulence and case details and associated images. host immunity remains unclear, rapid and accurate species identification can contribute to epidemiological tracing of outbreak strains 3. Discussion [13]. P. multocida is not susceptible to dicloxacillin, cephalexin, ery- Pasteurella species is highly prevalent among animal populations. thromycin, and clindamycin [2]. Of note, combination treatment with Previous literature has suggested that 20–30 human deaths occur amoxicillin and β-lactamase inhibitor clavulanic acid is effective [2]. every year worldwide because of pasteurellosis [2]. Although P. Although the treatment duration should be decided based on disease multocida occasionally colonizes immunocompetent patients, pneu- severity, at least 10–14 days of antibiotic treatment is recommended monia due to P. multocida is rare [2,5,6]. In 1993, Kopita et al. studied [1]. A previous study has reported that there is no correlation between the characteristics of 108 patients (mean age, 62 years; 65% male) length of exposure and disease severity [1]. However, a recent study with Pasteurella pleuropulmonary infection [1]. The common primary has suggested that pet owners who have more frequent close contact illnesses were pneumonia (45.3%), tracheobronchitis (34%), em- with dying animals are at risk for invasive P. multocida infection [4]. pyema (23%), and lung abscess (3%) [1]. Most of the patients had Because disease severity was thought to be associated with underlying underlying pulmonary diseases, including chronic obstructive pul- disease, the education of elderly or high-risk patients might be useful to monary disease, bronchiectasis, lung carcinoma, and pulmonary fi- avoid fatal pasteurellosis and its complications. In our case, P. multocida brosis [1]. The mortality rate of patients with Pasteurella pleur- pneumonia was successfully treated with β-lactam antibiotics for 5 opulmonary infection was documented as 30% [1]. Complications of weeks. We also educated the patient to avoid close contact with her pets hemoptysis have not been noted frequently. To the best of our and thereby successfully prevent recurrent hemoptysis. knowledge, only three hemoptysis cases have been reported in the In conclusion, we described a rare case of P. multocida pneumonia literature; most of these patients had a lung abscess with P. multocida with hemoptysis. The patient was successfully treated with antibiotic infection [7–9]. Because our patient had a history of bronchiectasis therapy. The number of elderly persons who own domestic animals is and because culture samples obtained from separate bronchial increasing in Japan. It is important to consider the possibility of P. washings revealed P. multocida infection at both sites, chronic Pas- multocida infection and to check whether patients keep household teurella infection may have affected the hemoptysis episodes. pets.

32 Y. Aida et al. Respiratory Medicine Case Reports 26 (2019) 31–34 A B

C Haemophilus influenzae M35019 0.005 Culture isolate1

Culture isolate2

Culture isolate3

Pasteurella multocida subsp. septica M75052

Pasteurella multocida subsp. gallicida AF294412

Pasteurella multocida subsp. multocida AF294410

Pasteurella canis AY362919

Pasteurella stomatis AY362925

Pasteurella dogmatis AY078999

Fig. 2. Bronchoscopy indicates a large amount of purulent sputum from the lingular segments (A). Gram staining revealed gram-negative rods in the bronchial wash specimen (B). Phylogenetic relationship of the Pasteurella species isolated from the culture (C). The partial 16S rRNA gene sequences from culture isolates were compared with the GenBank database using BLAST searches. In 1354 base pairs of the 16S rRNA gene sequences, the isolates showed a 99.9% identity match with the GenBank sequence M75052 (P. multocida subsp. septica). Bar = 0.5% sequence divergence.

Conflicts of interest Clin. Microbiol. Rev. 26 (2013) 631–655. [3] M. Seki, T. Sakata, M. Toyokawa, et al., A chronic respiratory pasteurella multocida infection is well-controlled by long-term macrolide therapy, Intern. Med. 55 (2016) The authors declare no potential conflicts of interest. 307–310. [4] E.M. Myers, S.L. Ward, J.P. Myers, Life-threatening respiratory pasteurellosis as- Acknowledgement sociated with palliative pet care, Clin. Infect. Dis. Off. Publ. Infect. Dis. Soc. Am. 54 (2012) e55–e57. [5] J. Ferreira, K. Treger, K. Busey, Pneumonia and disseminated bacteremia with The authors would like to thank Dr. Hitomi Shigemi, Professor of Pasteurella multocida in the immune competent host: a case report and a review of Infectious Diseases, University of Tsukuba, for his help in confirming the literature, Respir. Med. Case Rep. 15 (2015) 54–56. the diagnosis by 16S rRNA sequencing. [6] S. Pradeepan, S. Tun Min, K. Lai, Occupationally acquired Pasteurella multocida pneumonia in a healthy abattoir worker, Respir. Med. Case Rep. 19 (2016) 80–82. [7] D.A. Sazon, G.W. Hoo, S. Santiago, Hemoptysis as the sole presentation of References Pasteurella multocida infection, South. Med. J. 91 (1998) 484–486. [8] H.C. Maneche, H.W. Toll Jr., Pulmonary cavitation and massive hemorrhage caused by pasteurella multocida. Report of a case, N. Engl. J. Med. 271 (1964) 491–494. [1] J.M. Kopita, D. Handshoe, P.S. Kussin, et al., Cat germs! Pleuropulmonary pas- [9] E.C. Schmidt, L.V. Truitt, Koch ML Pulmonary abscess with empyema caused by teurella infection in an old man, N. C. Med. J. 54 (1993) 308–311. Pasteurella multocida. Report of a fatal case, Am. J. Clin. Pathol. 54 (1970) [2] B.A. Wilson, M. Ho, Pasteurella multocida: from zoonosis to cellular microbiology, 733–736.

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